What’s in Our Food? A guide to introducing effective front-of-package nutrient labels Citation: Vital Strategies and University of North Carolina at Chapel Hill. What’s in Our Food? A guide to introducing effective front-of-package nutrient labels. Trish Cotter1, Lindsey Smith Taillie2, Nandita Murukutla1, Luyanda Majija1, Alexey Kotov1, Marissa Hall2, Sandra Mullin1, Barry Popkin2. September 2020. 1 Vital Strategies 2 University of North Carolina at Chapel Hill Editors: Karen Schmidt and Dorian Block Design: Lizania Cruz and Karen Yung Special thanks to: Mercedes Mora, Luis Fernado Gomez, Isabella Higgins, Emily Busey, Pallavi Puri, Alejandro Calvillo, Rebecca Berner and Simón Barquera. Vital Strategies and University of North Carolina at Chapel Hill gratefully acknowledge Bloomberg Philanthropies for their generous support of this project. Front cover: Civil society groups in South Africa protesting for better regulations on how unhealthy packaged food is labeled. Source: Health-e News Service Creative commons license: This work is made available under the terms of the Creative Com- mons Attribution- NonCommercial-ShareAlike 4.0 International License. To view a copy of this license, visit http://creativecommons.org/ licenses/by-nc-sa/4.0/ or send a letter to Creative Commons, PO Box 1866, Mountain View, CA 94042, USA. The content in this document may be freely used in accordance with this license provided the material is accompanied by the follow- ing attribution: Vital Strategies and University of North Carolina at Chapel Hill. What’s in Our Food? A guide to introducing effective front-of-package nutrient labels. Trish Cotter1, Lindsey Smith Taillie2, Nandita Murukutla1, Luyanda Majija1, Alexey Kotov1, Marissa Hall2, Sandra Mullin1, Barry Popkin2. September 2020. 1Vital Strategies, 2University of North Carolina at Chapel Hill. Content 1 Overview 2 Step 1: Define the public health problem 8 Step 2: Understand the scientific basis for labels 11 Step 3: Review existing labels from other settings for local context 12 Step 4: Form an expert advisory committee 13 Step 5: Engage civil society 15 Step 6: Build public support 18 Step 7: Test label designs and identify an effective label 21 Step 8: Develop graphic design guidelines 22 Step 9: Evaluate policy impact 23 References 26 Appendix WHAT’S IN OUR FOOD? A guide to introducing effective front-of-package nutrient labels 1 WHAT’S IN OUR FOOD? A guide to introducing effective front-of-package nutrient labels Overview Labels on the front of food packages are an effective and efficient means of communication with consumers at the point of purchase. A number of countries have implemented or propose to implement front-of-package nutrient labels in an effort to communicate the (un)healthfulness of foods and beverages and to encourage healthy diets. This document may serve as a guidebook for governments, researchers, civil society groups and other stakeholders engaged in the development of front- of-package nutrient labels. It is built on previous experiences and outlines the key considerations and lessons learned in the process of developing an effec- tive front-of-package label. It is also built on a conceptual framework of how labels work, with the underlying objective of a nutrient labeling system to: 1) identify unhealthy foods and 2) discourage excess consumption of them. The steps include strategies for research, communication and development of a front-of-package nutrient label. This guide outlines these steps, with a greater emphasis on communication and research. Many of these activities can be implemented simultaneously; early planning of all of these activities is crucial to success. The steps, described in detail below, are: 1. Define the public health problem. 2. Determine scientific criteria for labels. 3. Review existing labels from other settings for local context. 4. Engage civil society. 5. Form an expert advisory committee. 6. Build public support. 7. Test label designs and identify an effective label. 8. Develop graphic design guidelines for implementing labels. 9. Evaluate policy impact. 2 WHAT’S IN OUR FOOD? A guide to introducing effective front-of-package nutrient labels STEP 1: Define the public health problem 1.1 WHY DO WE NEED FRONT-OF-PACKAGE NUTRIENT LABELS? Over 2 billion people—nearly one-third of the world’s population—are over- weight or obese, including more than 41 million overweight children under age 5. This global epidemic is a key driver of noncommunicable disease, which causes more than 70% of global deaths.1 Obesity and poor diet increase the risk of cancer, heart disease, stroke, Type 2 diabetes and related premature death. Undernutrition and obesity often coexist, as people increasingly consume cheap ultra-processed foods and drinks, which lack nutrients but are dense in fat and calories.2,3 Such unhealthy diets are estimated to be responsible for 11 million preventable deaths globally per year.4-6 The obesity epidemic places an unsustainable burden on individuals, govern- ments and society and is a growing problem in low- and middle-income countries, undermining health and economic development. As a result, policymakers and public health advocates alike are increasingly looking for policy levers to improve population nutritional status, in an effort to reduce the burden on health systems, support attempts to choose healthier options, and discourage consumption of ultra-processed foods and beverages.7,8 1.2 IMPORTANCE OF REDUCING CONSUMPTION OF ULTRA- PROCESSED PRODUCTS Colombia Bus stop poster that reads: “We have the right to informa- tion” was a part of Red PaPaz’s front-of-package nutrient labeling mass media campaign in 2018. Source: Red PaPaz archive 3 WHAT’S IN OUR FOOD? A guide to introducing effective front-of-package nutrient labels Increasingly, pre-packaged foods and beverages have become readily available in virtually every community across the globe, regardless of income level or population density.9-13 Combined with aggressive marketing of these products, this has dramatically changed the way people eat in many countries, displac- ing traditional diets and resulting in diets that are much less healthy.14-17 Ultra-processed foods are generally shelf stable, ready-to-eat or ready-to- heat, high in energy density and low in beneficial nutrients (e.g., fiber).18 Most of these pre-packaged foods are processed with high levels of added sugars, sodium, saturated fats and refined carbohydrates; research has found these nutrients of concern are connected to increased obesity and chronic nutri- tion-related diseases.19-23 In addition, the current state of research shows that excessive consumption of ultra-processed food contributes to poor dietary quality and obesity.3,24,25 There is extensive evidence from one major randomized controlled trial run by the U.S. National Institutes of Health26 and dozens of cohort studies that show increased consumption of ultra-processed foods is linked with increased overweight and obesity, diabetes, hypertension, cardiovascular disease, some Figure 1: Countries with mandatory or voluntary food labels MANDATORY Countries with either mandatory or voluntary VOLUNTARY interpretive labels on packaged foods Denmark Finland Iceland Lithuania Norway Sweden Denmark United Kingdom Czech Republic Mexico Poland Implementing Oct. 2020 Iran Slovenia Croatia Thailand Portugal, Spain Austria, Belgium Philippines France, Germany Ecuador Luxembourg Switzerland Nigeria Brunei United Arab Malaysia Emirates Peru Israel Sri Argentina Lanka Singapore Chile Uruguay Implementing Feb. 2021 Australia New Zealand Last updated September 2, 2020 | © Copyright 2020 Global Food Research Program UNC 4 WHAT’S IN OUR FOOD? A guide to introducing effective front-of-package nutrient labels cancers, and mortality.27-43 Reductions in unhealthy diet, particularly avoiding ultra-processed foods is key to reducing obesity.26 Furthermore, the consumption of ultra-processed products displaces the consumption of healthy foods, thereby limiting the consumption of other key ingredients and nutrients. To improve diet and health, leading health organi- zations such as WHO recommend reduction in consumption of these ener- gy-dense, micronutrient-poor foods as a critical measure to tackle the growing obesity epidemic.21,23,44-46 Consumers need access to clear information to identify unhealthy foods and beverages so they can make healthier choices. Not only have food and beverage products become less healthy over time, the sheer number of choices in stores makes it difficult and confusing for con- Figure 2: Typology of front-of-package labels related to health57 and nutrition. Note: The pictured labels are examples and not an exhaustive list of formats. Source: Ikonen I, Sotgiu F, Aydinli A, Verlegh PW. Consumer effects of front-of-package nutrition labeling: an interdisciplinary meta-analysis. Journal of the Academy of Marketing Science. 2020;48(3):360-383. Note: The pictured labels are examples and not an exhaustive list of formats. sumers to select healthier foods.47 Typically, shoppers take less than 10 seconds to select grocery items—not enough time to read and interpret many complicated nutrition facts panels.48-50 In essence, research has shown current back-of-the-package nutrition facts 5 WHAT’S IN OUR FOOD? A guide to introducing effective front-of-package nutrient labels panels do not work for quick, informed decision-making, and simpler, more effective options are needed.51,52 Adding to the confusion, unhealthy products may also feature misleading health and nutrition claims on their packages. Claims related to a particular nutrient (e.g., “high in calcium” or “low-fat”) and direct or indirect claims about a food’s potential health benefits can give an otherwise unhealthy product a “health halo effect,” leading consumers to misunderstand its nutritional quali- ty.53-56 Food packages are a highly effective means of communication with consumers at the point of decision-making and purchase. Marketers have long considered the food package as a premium channel for appealing to consumer preferences and purchases. Through attractive pack- aging, labeling and claims, marketers have sought to increase sales.